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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880558
Report Date: 07/18/2023
Date Signed: 07/18/2023 04:54:01 PM


Document Has Been Signed on 07/18/2023 04:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:PACIFIC VISTA SENIOR LIVING 2FACILITY NUMBER:
331880558
ADMINISTRATOR:TENG, JAMIEFACILITY TYPE:
740
ADDRESS:17081 BIRCH HILL RDTELEPHONE:
(951) 850-1088
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY:6CENSUS: 5DATE:
07/18/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Staff, Dominga AltobaTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted a visit to the facility for an unrelated matter and found deficiencies in the process. This report is to document those deficiencies. LPA met with staff, Dominga Altoba and spoke with licensee Jaime Teng over the phone and informed of the purpose of the visit.

LPA received notification from Riverside Community Hospital that Resident #1 (R1) had tested positive for MRSA infection. LPA spoke with licensee Jaime Teng who confirmed they had spoken verbally with a nurse at the hospital and been informed of the diagnosis around a week ago. LPA conducted a brief tour of the facility with PPE equipment and met with staff and explained the purpose of the visit and PPE. Staff stated they were unaware of R1's diagnosis. LPA spoke with licensee who stated they had not tested the remaining residents for MRSA for taken any action concerning the diagnosis. They stated they were waiting for paper work confirming the diagnosis from the hospital and had not received any. Additionally LPA observed the staff was not wear protective equipment during the visit.

Based on the above information, the facility failed to take the proper precautions to ensure the residents safety against communicable disease after being informed of a positive diagnosis for R1. Deficiencies were cited according to California Code of Regulations Title 22 Division 6 Chapter 8. Plan of correction was documented and created with licensee over the phone. An exit interview was conducted over the phone for this report, along with deficiency pages and appeal rights.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/18/2023 04:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: PACIFIC VISTA SENIOR LIVING 2
FACILITY NUMBER: 331880558

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/19/2023
Section Cited
CCR
87470(b)(1)

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(b)...when one or more residents in the facility are diagnosed with a contagious disease...(1)... maintain a safe and sanitary environment and to ...contain,...mitigate the transmission...This requirment was not met as evidenced by:
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The licensee agreed to report the infectious disease to department of public health, implemented saftey precautions, and send LPA an SIR for the incident by POC due date.
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Based on interviews and observation it was found that the facility has not taken any measures to migate or contain MSRA after R1 was diagnosed. This poses an immediate, health saftey or personal rights risk.
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The licensee will also send the LPA self certified statement of the above and precautions licensee will taken when they are informed of infectiouse in their facility.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
LIC809 (FAS) - (06/04)
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